The COVID-19 pandemic has shone a light on the need for improved mental health services. These services need to be better connected to rural communities.
This study used a telephone interview to ask participants about barriers to help-seeking for both physical and mental health issues. It compared these perceptions at domain and item level.
Access to Mental Health Services in Remote South Australia
In country South Australia, mental health services are less accessible than in metropolitan areas. Rural and regional residents access community mental health services at lower rates, are admitted to hospital for psychiatric care at higher rates, receive fewer follow-up services after discharge, and have less access to specialist psychiatric care than their metropolitan counterparts. This is a critical issue because poor mental health outcomes are associated with high levels of morbidity and mortality.
While there are a number of attitudinal barriers to help-seeking, the research has also shown that structural and system-level factors are major contributors to poor mental health outcomes. For example, navigating the healthcare system can be daunting for those living in rural areas because they are already juggling many responsibilities such as work, family, and school. Additionally, there are often a lack of resources and training in how to manage mental health issues, making it even more difficult to get appropriate care.
Furthermore, a lack of funding and resources can contribute to a fragmented health system that can make it hard for people to find adequate mental health services. This is particularly true in remote regions where there is a shortage of psychiatrists, psychologists, and nurses. This is exacerbated by the fact that some regional health services are run by non-governmental organisations (NGOs), which can make it difficult to access services unless they have a formal referral from a doctor or GP.
In our study, we surveyed 4,315 rural and remote South Australian adults on their perceived barriers to accessing support for mental health problems. Respondents were randomly selected from three regional districts in South Australia (Eyre Peninsula, Riverland, and Yorke Peninsula/Copper Coast) to complete a computer-assisted telephone interview. They were asked about their past-12-month treatment for mental disorders, the reasons why they did or did not seek help, and predictors of premature treatment dropout.
Cost barriers and limited provider availability were the most prevalent perceived barriers to seeking support. Specifically, one-third of women who needed and sought care but were unable to get an appointment reported that the main reason was that they could not afford it. This finding is consistent with the literature that finds that affordability is a leading barrier to health service use, especially among low-income populations.
Perceived Barriers to Accessing Mental Health Services in Remote South Australia
Mental health is a core component of well-being and contributes to social inclusion and economic development. It is therefore essential that all people have access to high-quality mental health care, including those living in remote regions. However, in countries like South Africa, where the majority of health care is public, this has proved to be a challenge. This is due to a lack of treatment facilities and a limited number of staff with the proper training and knowledge to address the needs of people with mental disabilities. This situation erodes the right to health as guaranteed by the CRPD.
In this study, 11 semi-structured interviews were conducted with respondents from tertiary and district hospitals and primary health care services in the Eastern Cape province. Six of the respondents were senior health professionals (chief psychiatrists and head nurses) and five worked in public administration, i.e., they were responsible for coordinating and managing the mental health service provision at the district level.
Respondents identified various barriers to the enjoyment of the right to health, especially those related to availability, accessibility and quality of health care services. The most common barrier is the physical availability of health care facilities, which is often impeded by a shortage of rooms. This is particularly problematic in the case of mental health care, since it requires time for consultations and a private space for discussion.
The scarcity of physicians is another significant issue. Respondents pointed out that they often have to manage without the expertise of a physician, which increases workloads for nurses and reduces efficiency. In addition, the scarcity of psychiatrists negatively impacts on access to treatment since it prevents patients from receiving adequate care and treatment.
The respondents also highlighted that the integration of mental health care into primary health care does not automatically guarantee an equal level of availability for all patients. Many respondents are worried that incorporating mental health care into general health care will lead to a reduction of the number of mental health clinics, thereby increasing travel times for patients seeking help in rural areas. They are also hesitant about health professionals holding traditional beliefs, which may negatively impact their ability to diagnose and treat patients adequately.
Perceived Benefits of Accessing Mental Health Services in Remote South Australia
In general, women who accessed mental health services in the past two years reported positive benefits of their experiences. They were more likely to report that they have access to care for their mood or anxiety, and the majority rated the quality of the service as high. However, they also cited the cost of care and lack of provider availability as barriers to getting help. These barriers could be addressed through increasing coverage or improving accessibility of services.
Respondents viewed psychosis as one of the most treatable mental health conditions and a number of them had experienced it themselves or a family member had experienced it. They described it as a combination of substance abuse and an emotional disturbance resulting in aggression and violence. However, they also pointed to a lack of awareness and knowledge among the population about lesser known mental disabilities such as depression or bipolar disorder. They suggested that this is due to the fact that policies, politicians and health reforms tend to focus on certain mental illnesses and disregard others.
While respondents felt that incorporating mental health into primary health care might be beneficial, they were concerned about the potential impact of this on the quality of care. They argued that without adequate staff training, the integration might lead to the misdiagnosis or undertreatment of mental health disorders. They also expressed a fear that insufficiently educated physicians might be more likely to rely on medication than on non-pharmacological interventions.
Respondents also pointed out that the COVID-19 pandemic created a new dynamic in terms of access to care for psychiatric conditions. The onset of the pandemic meant that more people needed to see providers and the wait list increased significantly. In addition, the cost of care increased for those who were not enrolled in insurance. This increased costs were a barrier for many who were not able to access mental health services and they did not receive the help they needed. In the future, telemedicine may play a greater role in helping to address these barriers and the majority of respondents who had used telehealth to seek mental health services reported that they were satisfied with the quality of the care.
Mental health services are delivered through a decentralized model that combines community-based mental health clinics with general hospitals having small psychiatric units. Primary health care nurses also provide outreach mobile services to remote communities. The system is complemented by a network of specialist services, including GPs with mental health training and psychologists. The COVID-19 pandemic caused disruptions to this model and has increased demand for telemental health interventions that are both time-efficient and geographically flexible.
Respondents from both service providers and patients reported barriers to accessing services, with the majority citing structural or system-based barriers. These barriers include long wait times for face-to-face appointments, a lack of availability and accessibility to appropriate services in remote locations, financial constraints on service utilisation, and a lack of suitable technology (e.g. tablets, smartphones). In contrast, respondents from rural communities reported attitudinal barriers. These included concerns about stigma associated with seeking help for a mental health condition, as well as fears of discrimination and rejection by peers.
Some of these obstacles can be addressed with policy changes, for example, through extending MBS item numbers to cover telehealth services. However, the underlying structural issues must be addressed to enable sustainable improvements in mental health service delivery in remote Australia.
Several strategies have been proposed to address these issues, for example, through introducing incentives, changing attitudes and increasing awareness. However, as these factors are complex and will continue to change over time, it is important that policy interventions take into account the realities of rural and remote communities.
Another obstacle identified by respondents is the lack of facilities to accommodate mental health patients. This is particularly problematic during the pandemic when there are shortages of rooms at general hospitals. Currently, some tertiary-level hospital sites have established 72-hour emergency observation units to decrease unnecessary admissions to psychiatric inpatient facilities.
In addition to ensuring that appropriate policies are put in place, it is important to monitor the implementation of the right to health. This can be done through the use of an accountability framework, as suggested by the AAAQ. This framework can be used to identify gaps between existing laws and actual progress toward the fulfillment of rights, particularly for people with disabilities. The results of this study, combined with other research, suggest that the current system is far from meeting its obligations towards people with disabilities.